Advantages of the treatment of aneu risms by excision: 1. If the operation can be successfully performed the result is a complete cure of the aneurism. 2. The ligatures have the advantage of be ing applied to the ends of the divided vessels, and not to them in their con tinuity. 3. Even if the corresponding vein is divided and a portion of it re moved the risk of gangrene is not great. 4. That in this method all the advan tages of the antiseptic treatment can be obtained, in connection with the success ful healing of the wound and closure of the vessels where divided. 5. Inflamma tion and suppuration of the sac or rupt ure of it cannot occur in connection with this method. 6. Although as yet more experience is required, it seems likely that certain aneurisms, such as the sub clavian, will in the future be treated more successfully by this method. T. Annandale (Scottish Med. and Surg. Jour., Oct.. 1900).
Aortic Aneurism.
Symptoms. — Aneurisms may be di vided into three groups: (1) those which are entirely latent, giving no physical signs; (2) those giving signs of thoracic pressure, but in which the na ture of the cause cannot be ascertained; (3) aneurisms which form distinct tu mors and give well-marked pressure symptoms and external signs. (Bram well.) Aneurisms of the ascending portion of the arch are those most liable to affect the sympathetic. Reflex dilatation of the pupil may thus be caused; the face may be pale. When the cilio-spinal branches arc destroyed the pupil is contracted; the vessels of the side of the head may be dilated. Congestion and unilateral perspiration are also, though less fre quently, observed.
Tugging on the trachea is a valuable symptom, and may be detected in the following manner: The patient's head being inclined forward to relax the neck, and the cricoid cartilage being grasped between the index and the thumb, the trachea is drawn upward. If an aneu rism is present a well-marked ascending motion will be felt at each pulsation. Olivier's symptom for diagnosis of aneu rism of thoracic aorta, systolic pulsation of the larynx and trachea, is not to be expected in all aneurisms of the aortic arch, but is especially to be observed, either when the aneurism is situated ex actly at the intersection of the aortic arch and bronchus or when, if the aneu rism is situated at the beginning of the arch, it is adherent to the anterior wall of the trachea. The only other patho logical condition which one might expect to produce similar symptoms ix a tumor in the anterior mediastinum. This must
hold certain relations to the aortic arch, either through pressure exerted by the arch, the tumor is pressed against the bronchus. or it must be adherent to the convexity of the arch and to the trachea. A. Fraenkel (Deutsche med. Woch., .Tan. 5, '99). ' At times a systolic murmur is caused in the trachea by the air being forced out of it during the systole. The sound, however. may also be caused by the sac. It may be heard at the patient's mouth when the latter is well opened. Trac tion of the tongue causes this symptom to become more distinct.
In two cases a rhythmical shake of the head observed, synchronous with the car diac systole and clue to downward trac tion of left bronchial tube and trachea by the aneurism at each diastole. Feletti (La Semaine AIPd, NOV. 6. '95).
Pain is especially marked in deep seated tumors. Angina pectoris fre quently occurs in aneurisms situated at the root of the aorta.
Cough in thoracic aneurism may be due to bronchitis, or it may be caused by pressure on the trachea. The expectora tion is at first abundant and watery; later on it is thick and turbid.
On percussion large aneurisms pre sent abnormal dullness. This dullness is toward the right when an aneurism of the ascending arch is present, and more to the centre and left in those of the transverse arch. Aneurisms of the de scending portion of the arch show dull ness in the left interscapular region: i.e., in the space between the spinal column and the scapular border.
A ringing, accentuated, second sound, heard over a dull region, is frequent in large aneurisms of the arch.
Absence of pulse in the abdominal aorta and its branches is observed in eases of large thoracic aneurism.
Case of aneurism of the aortic arch in which the pulse of the carotids and right radial arteries had the reversed character of the pulses paradoxus. There was a very marked diminution in the volume of the pulse during expiration, and with the respiratory variations there was a definite ana erotic wave. Post-mortem examination showed an aneurism involving chiefly the posterior portion of the aorta in the region of the transverse arch. The left carotid and innominate arteries sprang from the anterior surface of the arch instead of from the convexity, on ac count of the distension of the aorta. With each expiratory excurse these blood-vessels were compressed against the bony thorax-walls. J. Hay (Lancet, Apr. 27, 1901).